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    Exogenous Ochronosis in Facial Lichen Planus Pigmentosus

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    Lichen planus pigmentosus is a chronic inflammatory pigmentary dermatosis considered a rare variant of the cutaneous lichen planus. It is characterized by acquired dark brown to gray macular pigmentation involving sun-exposed areas commonly found in dark-skinned patients. Exogenous ochronosis is an acquired cause of blue-gray to black pigmentation involving the skin and mucous tissues. We report a case of exogenous ochronosis occurring in a 45-year-old patient treated for lichen planus pigmentos

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    Exogenous Ochronosis in Facial Lichen Planus Pigmentosus

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    Lichen planus pigmentosus is a chronic inflammatory pigmentary dermatosis considered a rare variant of the cutaneous lichen planus. It is characterized by acquired dark brown to gray macular pigmentation involving sun-exposed areas commonly found in dark-skinned patients. Exogenous ochronosis is an acquired cause of blue-gray to black pigmentation involving the skin and mucous tissues. We report a case of exogenous ochronosis occurring in a 45-year-old patient treated for lichen planus pigmentos

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    Lichen planus pigmentosus is a chronic inflammatory pigmentary dermatosis considered a rare variant of the cutaneous lichen planus. It is characterized by acquired dark brown to gray macular pigmentation involving sun-exposed areas commonly found in dark-skinned patients. Exogenous ochronosis is an acquired cause of blue-gray to black pigmentation involving the skin and mucous tissues. We report a case of exogenous ochronosis occurring in a 45-year-old patient treated for lichen planus pigmentos

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    20 views7 pages

    Exogenous Ochronosis in Facial Lichen Planus Pigmentosus

    Uploaded by

    Athenaeum Scientific Publishers
    Lichen planus pigmentosus is a chronic inflammatory pigmentary dermatosis considered a rare variant of the cutaneous lichen planus. It is characterized by acquired dark brown to gray macular pigmentation involving sun-exposed areas commonly found in dark-skinned patients. Exogenous ochronosis is an acquired cause of blue-gray to black pigmentation involving the skin and mucous tissues. We report a case of exogenous ochronosis occurring in a 45-year-old patient treated for lichen planus pigmentos

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    © All Rights Reserved
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    of 7

    Journal of Dermatology Research

    Open Access Case Report

    Exogenous Ochronosis in Facial Lichen Planus Pigmentosus

    Selma El Kadiri1*, Hanane Bay Bay1, Imane Kacimi1, Zakia Douhi1, Sara Elloudi1, Fatima-Zahra
    Mernissi1, Layla Tahiri2, Nawal Hammas2, Leila Chbani2, Hinde El Fatemi2
    1
    Department of Dermatology, CHU Hassan II, Fez, Morocco
    2
    Anatomopathology Department, CHU Hassan II, Fez, Morocco

    *Corresponding Author: Selma El Kadiri, Department of Dermatology, CHU Hassan II, Fez, Morocco;
    E-mail: [email protected]

    Received Date: 06-03-2021; Accepted Date: 23-04-2021; Published Date: 30-04-2021

    Copyright© 2021 by Kadiri SE, et al. All rights reserved. This is an open access article distributed under the terms
    of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
    any medium, provided the original author and source are credited.

    Abstract
    Lichen planus pigmentosus is a chronic inflammatory pigmentary dermatosis considered a rare
    variant of the cutaneous lichen planus. It is characterized by acquired dark brown to gray
    macular pigmentation involving sun-exposed areas commonly found in dark-skinned patients.
    Exogenous ochronosis is an acquired cause of blue-gray to black pigmentation involving the
    skin and mucous tissues. We report a case of exogenous ochronosis occurring in a 45-year-old
    patient treated for lichen planus pigmentosus. She was treated with Kligman formula
    containing hydroquinone. The patient presented to our Department for progressive worsening
    of the malar pigmentation. Dermoscopy revealed gray to black rounded and homogeneous
    areas with arciform structures obliterating the follicular openings and telangiectasic vessels
    making us suspecting exogenous ochronosis confirmed by histology.

    Keywords
    Lichen Planus Pigmentosus; Exogenous Ochronosis; Dermoscopy; Histology

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106
    2

    Introduction
    Lichen planus pigmentosus is a chronic inflammatory pigmentary dermatosis considered a rare
    variant of the cutaneous lichen planus. It is characterized by acquired dark brown to gray
    macular pigmentation involving sun-exposed areas commonly found in dark-skinned patients.
    Exogenous ochronosis is an acquired cause of blue-gray to black pigmentation involving the
    skin and mucous tissues. We report a case of exogenous ochronosis occurring in a patient
    treated for lichen planus pigmentosus.

    Patient and Observation


    A 45-year-old postmenopausal, phototype IV, presented with a history of 10 years of frontal
    recessing line, eyebrow loss, and brown-gray pigmentation of both cheeks. A skin biopsy of
    both pigmented lesions and scalp alopecia was compatible with the diagnosis of lichen planus
    pigmentosus and frontal fibrosing alopecia. The patient was treated with chemical
    photoprotection, doxycycline, and Kligman preparation containing hydroquinone 5%, retinoic
    acid 0.2%, hydrocortisone 1%, and vitamin C for four months. The follow-up was lost. She
    applied the treatment by self-medication for two years without interruption. She presented to
    our Department for progressive worsening of the malar pigmentation. Dermatological
    examination showed hyperchromic, gray-brown macules in the zygomatic areas with frontal
    recessing line and eyebrow loss (Fig. 1 and 2). Dermoscopy revealed gray to black rounded
    and homogeneous areas with arciform structures obliterating the follicular openings and
    telangiectasic vessels (Fig. 3 and 4) making us suspecting exogenous ochronosis. Dermoscopy
    showed also regularly distributed brown-grey globules and dots compatible with a facial lichen
    planus pigmentosus (Fig. 5).

    Histopathological examination revealed ochronotic pigment represented by ovoid bodies and


    bananas in the dermis compatible with the diagnosis of exogenous ochronosis (Fig. 6). We
    forbad the use of topical depigmenting agents containing hydroquinone.

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106
    3

    Figure 1: Hyperchromic, grey-brown macules in the zygomatic areas with frontal recessing
    line and eyebrow loss.

    Figure 2: Hyperchromic, grey-brown macules in the zygomatic areas with frontal recessing
    line and eyebrow loss.

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106
    4

    Figure 3: Exogenous ochronosis. Dermoscopy showing grey to black rounded with arciform
    structures (blue triangle).

    Figure 4: Exogenous ochronosis. Dermoscopy showing arciform structures and


    telangiectasic vessels.

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106
    5

    Figure 5: Lichen planus pigmentosus. Dermoscopy showing regularly distributed brown-


    grey globules and dots.

    Figure 6: Histology showing ochronotic pigment represented by a banana structure like (red
    triangle).

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106
    6

    Discussion
    Ochronosis was first described by Virchow in 1866 to describe a blue-black cutaneous
    pigmentation in the skin associated with an ochre pigment deposition in microscopy [1]. They
    are two main types: alkaptonuria and exogenous ochronosis. Alkaptonuria is an autosomal
    recessively inherited condition due to deficiency of Homogentisate 1,2-dioxygenase (HGD) in
    the liver and kidneys leading to an accumulation of homogentisic acid in the skin, cartilage,
    and fibrous tissues [2]. Exogenous ochronosis has been reported following the long-term use
    of bleaching creams containing hydroquinone, resorcinol, picric acid, mercury, and
    antimalarials is a chronic dermatosis characterized by the presence of blue-black or grey-blue
    pigmentation of the skin and mucous tissue. This condition affects dark skin phototypes. The
    exact pathogenesis of exogenous ochronosis is not completely elucidated. It is thought to be
    the result of an inhibition of HGD by hydroquinone leading to an oxidation of homogentisic
    acid and photo-oxidation [3]. Dogliotte and al classified exogenous ochronosis into three
    clinical stages:

    1. Erythema and mild hyperpigmentation


    2. Colloid milium lesions and atrophy
    3. Papulo-nodular lesions.

    The lesions occur particularly over bony prominences such as the temples, forehead, and lower
    jaws [2]. Dermoscopy shows irregular globular structures that are brown-gray, brown-gray,
    annular, and arciform, sometimes obliterating the follicular openings. They correspond
    histologically to ochronotic pigment distributed in the superficial dermis into yellow-brown,
    sharply defined fragmented fibers [4]. We did not find reports in the literature of exogenous
    ochronosis occurring in facial lichen planus pigmentosus. Dermoscopy of lichen planus
    pigmentosus can show dark brown to grey dots and globules of smaller size sparing the
    follicular openings. They can be distributed in arciform configuration but they are thin not as
    thick in ochronosis [5]. Various therapeutic agents have been used to treat exogenous
    ochronosis without complete clearance of the condition. Topical retinoic acid, glycolic acid,
    and topical corticosteroid were been used with partial improvement. Combined treatment of
    dermabrasion and CO2 laser showed improvement of the lesions [3]. The Q-switched
    alexandrite laser has been reported to be effective to clear ochronotic pigment from the dermis
    [6].

    Another study showed satisfactory results proven histologically with Q switched Nd Yag laser
    [7].

    The particularity of our case is the occurrence of exogenous ochronosis in facial lichen planus
    pigmentosus and not in melasma lesions. We want also to highlight the usefulness of

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106
    7

    dermoscopy in the follow-up of lichen planus pigmentosus since it allowed us to distinguish


    the two conditions.

    Conclusion
    We highlight the fact that hydroquinone prescription should be evaluated by practitioners to
    detect early side effects such as exogenous ochronosis and the contribution of dermoscopy to
    distinguish lichen planus pigmentosus from exogenous ochronosis.

    References
    1. Virchow R. XV. Ein Fall von allgemeiner ochronose der Knorpel und knorpelälinliclien Tlieile. In Band.
    1866;212-9.
    2. Charlín R, Barcaui CB, Kac BK, Soares DB, Rabello-Fonseca R, et al. Hydroquinone-induced exogenous
    ochronosis: a report of four cases and usefullness of dermoscopy. Int J Dermatol. 2007;47(1):19-23.
    3. Bhattar PA, Zawar VP, Godse KV, Patil SP, Nadkarni NJ, et al. Exogenous ochronosis. Indian J Dermatol.
    2015;60(6):537-43.
    4. Jha AK, Sonthalia S, Lallas A. Image Gallery: Dermoscopy as an auxiliary tool in exogenous ochronosis. Br
    J Dermatol. 2017;177(2):e28.
    5. Chatterjee Manas, Shekhar Neema. Dermoscopy pigmentary disorders in brown skin. Dermatol Clin.
    2018;36:473-85.
    6. Bellew SG, Alster TS. Treatment of exogenous ochronosis with a Q-switched alexandrite (755 nm) laser.
    Dermatol Surg. 2004;30(4):555-8.
    7. Tan SK. Exogenous ochronosis-successful outcome after treatment with Q-switched Nd: YAG laser. J
    Cosmet Laser Ther. 2013;15:274-8.

    Kadiri SE | Volume 2; Issue 1 (2021) | JDR-2(1)-021 | Case Report

    Citation: Kadiri SE, et al. Exogenous Ochronosis in Facial Lichen Planus Pigmentosus. J Dermatol Res.
    2021;2(1):1-7.

    DOI: http://dx.doi.org/10.46889/JDR.2021.2106

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